Assessment of outcome following Ayurveda treatment protocol was done in a complicated case of spinal fracture with motor dysfunction and having a past history of Pott's disease. A 52-year-old man was suffering from motor dysfunction after a spinal fracture at D5/D6 level. The patient sought Ayurveda treatments because he did not gained any significant improvement according to mainstream medical treatments what he underwent for several years. According to Ayurveda, the patient was treated following immobilization, external and internal application of herbal preparations followed by physiotherapy. The outcome of the treatments were monitored by motor function assessment, quality of life assessment and computed tomography scan. Initial signs of improvement were observed just after 1 month of commencing Ayurveda treatments. Continuously following the treatments for 24-month duration, the patient was reverted back to his normal life. This complicated case of spinal fracture was successfully cured using Ayurveda treatment. Therefore, the observations made here would be useful for organizing a future clinical trial.

The traditional medical system practiced in Sri Lanka is a subdivision of Ayurveda. It is widely believed that Ayurveda fracture management is promising, thus herbs composite in Ayurveda treatments likely facilitate the bone growth at the fracture site.

Mainstream medical practice (Western medicine) basically applies bone reduction, immobilization and physiotherapy in fracture management. In present era, Ayurveda also follows the same procedure of bone reduction, immobilization as mentioned in classic along with physiotherapy.[1] However, in addition to that, in between immobilization and physiotherapy, the external and internal application of various herbal medications makes the improved outcome of Ayurveda fracture healing compared to allopathic medicine.

Among the bone fractures, vertebral fractures are more critical and life threatening.[2] Many people living with a spinal cord injury tend to develop depression as a result of lifestyle changes.[3]

Here, we present a case report of a person who had recovered successfully following Ayurveda treatment with vertebra fracture and spinal tuberculosis who initially followed mainstream medical advice for several years' without a success.

Case Report

A 52-year-old taxi driver was suffering from chronic back pain from 10 years. During the last 3 years, his back pain became progressively worse and developed numbness in both lower limbs.

Following the consultation of neurologist at a hospital at Kandy, a computed tomography (CT) was done in 2012 and diagnosed as infective spondylitis at D5/D6 level of the dorsal spine. It was identified as Pott's disease (spinal tuberculosis). Anti-tubercular therapy (ATT), was given for 1-year period. After ATT, the patient was unable to walk without support. After that, he was referred to neurology unit. While he was in neurology unit, he suffered accidental fall from the bed causing him unable to move his lower limbs, but his sphincter control was intact (sensory intact with motor defect). Repeated CT of dorsal spine showed D5/D6 fracture [Figure 1]a. Since his condition did not improved, he was asked to take follow-up at the rehabilitation unit for conservative management, which was continued up to 1 year at rehabilitation unit. Observing no improvement, the patient decided to seek Ayurveda treatment starting from June 2013.

At the time of reporting for Ayurvedic consultation and management, patient complained of a heaviness and numbness over lower body and difficulty to move his legs. He could not bend and raise his lower limbs. The patient was treated using three treatment regimens while assessing the outcome at the end of each regimen.

Treatment regimen 2 (6–12 months): Triphala decoction (30 ml) treatment was continued for next 6 months in the same dose similar to first 6 months. In addition to that, Pinda oil[4] (30 ml) with paste of Katakala (60 g) was applied topically daily. Dantimooladi decoction[4] 120 ml was administered twice a day in the first 3 months of this phase. In the second 3-month period, Dashamoola-Bala-Eranda decoction[4] (120 ml) was given. The patient recovered from symptoms of numbness and heaviness along with gaining ability to move his lower limbs

Treatment regimen 3 (12–24 months): During this period, Tarpana Chikitsa which was continued throughout 12-month period along with application of Narayana oil[4] (30 ml) with paste of Ashwagandhadi[4](60 g), externally. Maharasnadi decoction[4] (120 ml) was administered twice a day at initial 3 months of this phase and after that Masha-Baladi decoction[4] (120 ml) was started twice a day for the remaining 9 months.

The fractured bone was immobilized using lumbar thoracic corset. It was applied throughout the day in the 1st year and after that until the treatment concludes it was applied over the day time only. Altogether, after 24 months of commencing initial treatment, the patient recovered completely.

Preparation of drugs

Seethodaka oil was prepared according to the classical text of Ayurveda Pharmacopeia.[4]Pinda oil and Narayana oil were prepared according to the classical text Bhaishajya Ratnavali.[5]Triphala decoction, Vasa-Guduchi decoction, Gandharava-Hastadi decoction, Dantimooladi decoction, Dashamoola-Bala-Erandadi decoction, Maharasnadi decoction and Masha-Baladi decoction were prepared according to the guidelines and methods mentioned by the classical text of Ayurveda Pharmacopeia.[4]

Motor function assessment[6] with the time, after commencing the Ayurveda treatment [Table 2].

Quality of life assessment

Quality of life was assessed before the treatment, 1 month, 3 months, 6 months, 1 year, 18 months and 3 years of the treatment. Quality of Life was assessed by the ferrans and powers quality of life index (FPQLI) spinal cord injury version-III.[7]

At the commencement of treatment, the total quality of life score was 84/420. Following 3 months, the 4 subscales increased significantly (P < 0.05). After 24 months of commencing the treatment, the patient recovered and the total score of FPQLI became 410/420 (P = 0.02) [Table 3].

Table 3: Assessment of quality of life with the time, after commencing Ayurveda treatment

Statistical analysis was conducted using Wilcoxon signed rank test. Statistical software SAS version 9.1 (New Jersey, USA. 2005) was used for the analysis. Initially, from 1 to 6-month period, the parameters were compared at 3-month intervals. After 6 months, until completion of treatment, it was compared at 6-month intervals.

Discussion

A wide range of herbal applications in fracture management has been mentioned in Ayurveda scripts which facilitate the bone growth and helps in remolding of callus. In present case study, the patient presented with a vertebral fracture and likely spinal cord compression/damage, causing paralysis of lower part of the body.

After 24 months of commencing of Ayurveda treatment, the tone, power, knee jerk and ankle jerk became normal indicating that the motor neuron functions were restored. In our treatment procedure, oral and topical applications were used with large number of herbs. All the medicines were used to facilitate the bone healing mechanism. Oral and topical medicine were selected as per the treatment principles of Shodhana Chikitsa (purificatory treatment), Shamana Chikitsa (pacificator treatment) and Tarpana Chikitsa (nourishment treatment). The treatment commenced with Shodhana Chikitsa of Virechana Karma to correct the deranged Dosha (Vata and Kapha) which signifies the concept of eradicating the disease. The Shodhana Chikitsa of Virechana Karma comprises the Ama-Pachana (enhancing the digestive power) and Purva Karma (preparatory purification process). To achieve the process of Purva Karma, Snehana Karma (oleation therapy) and fomentation were applied over the fractured area. Seethodaka oil and paste of Katakaladi were applied for the Virechana Karma of Shodhana Chikitsa and it probably regularized the blood circulation around the fractured bone. It initiates the formation of hematoma subsequently resolving into granulation tissue with the typical inflammatory cascade. In this case, it is in a nonunion state thus Virechana Karma of Shodhana treatment would trigger the granulation tissue formation which subsequently leading to soft callus and finally trigger the hard callus formation. Initial 6-month period topical (Seethodaka oil and Katakaladi paste) and oral medicines (Triphala decoction, Vasa-Guduchiyadi decoction and Gandharva-Hastadi decoction) were selected which has properties of Virechana while next 6 months medicines were administered having properties of Shamana. Last 1-year period, oral and topical Tarpana medicines were administered to enhance the strength of the bones, nerves and muscles.

Following fracture, the Kapha and Vata Dosha are prominent around the fractured area. Pain and swelling are due to Dosha Vriddhi (increased Vata and Kapha Dosha) However, the basic treatment plan was to normalize the Vriddhi (increase) and Ksheena (decrease) Dosha over the fractured bone. The herbs used in the treatment regimes, possess different pharmacological and biological properties.[8] Ingredients of Thriphala decoction, Vasa-Guduchi decoction, Gandharva-Hastadi decoction possess property for Virechana Karma; Dantimooladi, Dashamula-Bala-Eranda and Maha-Rasnadi decoction has Shamana property and Masha-Baladi decoction has Tarpana property. Sheetodaka oil possess Virechana property, Pinda oil has Shamana property and Narayana oil has Tarpana property. Paste of Katakaladi has both Virechana and Shamana property. Paste of Ashwagandhadi has the Tarpana property. Main ingredient of the Ashwagandhadi paste is Withania somnifera (L.) Dunal which is capable of enhancing muscle strength leading to recovery.[9] All the medicines possess the properties of Vata-Shamana (pacify the vitiated Vata), Vedana-Sthapana (sedative), Shoola-Prashamana (analgesic), Tarapana (enhance the nutrition), Balya (promote strength) and Sroto-Shodhana (purify the channels) which help to improve the qualities of Asthi-Dhatu (bones) and reformation of wasting tissues.[10]

Further, herbs in the treatment procedure, have antioxidant and anti-inflammatory properties. Jambu (Syzygium cumini (Linn) skeel's) has Sheeta Virya (cool potency) and it is a diuretic. It is a main ingredient of the paste of Katakala. Haritaki and Vibhithaka have a Ushna Virya (hot potency) and it possess anti-inflammatory property. Phylanthus emblica (Dhatri) has also antioxidant and anti-inflammatory activities. In this study Sheetodaka oil was used for Shodhana Chikitsa (purificatory treatment) which consists of Nimba (Melia azadirachta) and also possess Shodhana (purificatory) and Ropana (healing) properties. It purifies blood surrounding the fractured area and regulates blood circulation around the nonhealing fracture. Free radicals are associated with inflammation, swelling, further breakdown of bone collagen and excessive bone turnover. The antioxidants neutralize free radicals.[11] In addition to that, applying a hot, fresh burdock leaf poultice reduces the swelling induced by a fracture.[10],[12],[13],[14]

In present case, patient was on ATT for 1 year and another 1 year later when presenting to Ayurveda treatment CT scan showed a fracture. Also, motor function assessment and FPQLI spinal cord injury version-III showed signs/symptoms of spinal cord compression with poor quality of life respectively. This would imply prior to Ayurveda treatment, patient was ill.

In summary, first 6 months period, Shodhana Chikitsa was started which would have facilitated the granulation tissue formation over fractured area. After Virechana Karma as Shodhana Chikitsa, Shamana Chikitsa was initiated topically and orally, which might had influenced the body as a whole. Shamana Chikitsa might had enhanced the balance more toward osteoblast formation and induced nervous system. Finally, the Tarpana Chikitsa, might had led to strengthening of muscles, nervous system and remoulding the bone, thus, delivered a better outcome.[15],[16]

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his name and initials will not be published and due efforts will be made to conceal has identity, but anonymity cannot be guaranteed.

Acknowledgment

The patient of this case report was managed at the Bandaranaike Memorial Ayurveda Research Institute, Colombo, Sri Lanka.